Summary of Notice of Privacy Practices
This summary is provided to assist you in understanding the Notice of Privacy Practices below.
The Notice of Privacy Practices below contains a detailed description of how our office will protect your health information, your rights as a patient and our common practices in dealing with patient health information. Please refer to that Notice for further information.
Uses and Disclosures of Health Information. We will use and disclose your health information in order to treat you or to assist other health care providers in treating you. We will also use and disclose your health information in order to obtain payment for our services or to allow insurance companies to process insurance claims for services rendered to you by us or other health care providers. Finally, we may disclose your health information for certain limited operational activities such as quality assessment, licensing, accreditation and training of students.
Uses and Disclosures Based on Your Authorization. Except as stated in more detail in the Notice of Privacy Practices, we will not use or disclose your health information without your written authorization.
Uses and Disclosures Not Requiring Your Authorization. In the following circumstances, we may disclose your health information without your written authorization:
• To family members or close friends who
are involved in your health care;
• For certain limited research purposes;
• For purposes of public health and safety;
• To Government agencies for purposes of
their audits, investigations and other
oversight activities;
• To government authorities to prevent
child abuse or domestic violence;
• To the FDA to report product defects or
incidents;
• To law enforcement authorities to
protect public safety or to assist in
apprehending criminal offenders;
• When required by court orders, search
warrants, subpoenas and as otherwise
required by the law.
Patient Rights. As our patient, you have the following rights:
• To have access to and/or a copy of your
health information;
• To receive an accounting of certain
disclosures we have made of your health
information;
• To request restrictions as to how your
health information is used or disclosed;
• To request that we communicate with
you in confidence;
• To request that we amend your health
information;
• To receive notice of our privacy
practices.
If you have a question, concern or
complaint regarding our privacy practices,
please refer to the Notice of
Privacy Practices below for the person or persons
whom you may contact.
_______________________________________
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US.
Our Legal Duty
We are required by applicable federal and state laws to maintain the privacy of your protected health information. We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your protected health information. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect 9/23/2013, and will remain in effect until we replace it.
We reserve the right to change our privacy practices and the terms of this notice at any time, provided that such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all protected health information that we maintain, including medical information we created or received before we made the changes.
You may request a copy of our notice (or any subsequent revised notice) at any time. For more information about our privacy practices, or for additional copies of this notice, please contact us using the information listed at the end of this notice.
Uses and Disclosures of Protected Health Information
We will use and disclose your protected health information about you for treatment, payment, and health care operations.
Following are examples of the types of uses and disclosures of your protected health care information that may occur. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office.
Treatment: We will use and disclose your protected health information to provide, coordinate or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. We will also disclose protected health information to other physicians who may be treating you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.
In addition, we may disclose your protected health
information from time to time to another physician or
health care provider (e.g., a specialist or laboratory)
who, at the request of your physician, becomes
involved in your care by providing assistance with your
health care diagnosis or treatment to your physician.
Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you, such as: making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for protected health necessity, and undertaking utilization review activities. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.
Health Care Operations: We may use or
disclose, as needed, your protected health information
in order to conduct certain business and operational
activities. These activities include, but are not limited
to, quality assessment activities, employee review
activities, training of students, licensing, and
conducting or arranging for other business activities.
For example, we may use a sign-in sheet at the
registration desk where you will be asked to sign your
name. We may also call you by name in the waiting
room when your doctor is ready to see you. We may
use or disclose your protected health information, as
necessary, to contact you by telephone or mail to
remind you of your appointment.
We will share your protected health information
with third party “business associates” that perform
various activities (e.g., billing, transcription services)
for the practice. Whenever an arrangement between our
office and a business associate involves the use or
disclosure of your protected health information, we
will have a written contract that contains terms that will
protect the privacy of your protected health
information.
Sale of Health Information: We will not sell or
exchange your health information for any type of
financial remuneration without your written
authorization.
Fundraising Communications: We may use or
disclose your health information for fundraising
purposes, but you have the right to opt-out from
receiving these communications.
Uses and Disclosures Based On Your Written
Authorization: Other uses and disclosures of your
protected health information will be made only with
your authorization, unless otherwise permitted or
required by law as described below.
You may give us written authorization to use your
protected health information or to disclose it to anyone
for any purpose. If you give us an authorization, you
may revoke it in writing at any time. Your revocation
will not affect any use or disclosures permitted by your
authorization while it was in effect. Without your
written authorization, we will not disclose your health
care information except as described in this notice.
Others Involved in Your Health Care: Unless
you object, we may disclose to a member of your
family, a relative, a close friend or any other person
you identify, your protected health information that
directly relates to that person’s involvement in your
health care. If you are unable to agree or object to such
a disclosure, we may disclose such information as
necessary if we determine that it is in your best interest
based on our professional judgment. We may use or
disclose protected health information to notify or assist
in notifying a family member, personal representative
or any other person that is responsible for your care of
your location, general condition or death.
Marketing: We may use your protected health
information to contact you with information about
treatment alternatives that may be of interest to you.
We may disclose your protected health information to a
business associate to assist us in these activities. If we
are paid by a third party to make marketing
communications to you about their products or
services, we will not make such communications to
you without your written authorization. Except as
stated above, no other marketing communications will
be sent to you without your authorization.
Research; Death; Organ Donation: We may use
or disclose your protected health information for
research purposes in limited circumstances. We may
disclose the protected health information of a deceased
person to a coroner, protected health examiner, funeral
director or organ procurement organization for certain
purposes.
Public Health and Safety: We may disclose your protected health information to the extent necessary to avert a serious and imminent threat to your health or safety, or the health or safety of others. We may disclose your protected health information to a government agency authorized to oversee the health care system or government programs or its contractors, and to public health authorities for public health purposes.
Health Oversight: We may disclose protected
health information to a health oversight agency for
activities authorized by law, such as audits,
investigations and inspections. Oversight agencies
seeking this information include government agencies
that oversee the health care system, government benefit
programs, other government regulatory programs and
civil rights laws.
Abuse or Neglect: We may disclose your
protected health information to a public health
authority that is authorized by law to receive reports of
child abuse or neglect. In addition, we may disclose
your protected health information if we believe that
you have been a victim of abuse, neglect or domestic
violence to the governmental entity or agency
authorized to receive such information. In this case, the
disclosure will be made consistent with the
requirements of applicable federal and state laws.
Food and Drug Administration: We may
disclose your protected health information to a person
or company required by the Food and Drug
Administration to report adverse events, product
defects or problems, biologic product deviations, to
track products; to enable product recalls; to make
repairs or replacements; or to conduct post marketing
surveillance, as required.
Criminal Activity: Consistent with applicable
federal and state laws, we may disclose your protected
health information, if we believe that the use or
disclosure is necessary to prevent or lessen a serious
and imminent threat to the health or safety of a person
or the public. We may also disclose protected health
information if it is necessary for law enforcement
authorities to identify or apprehend an individual.
Required by Law: We may use or disclose your
protected health information when we are required to
do so by law. For example, we must disclose your
protected health information to the U.S. Department of
Health and Human Services upon request for purposes
of determining whether we are in compliance with
federal privacy laws. We may disclose your protected
health information when authorized by workers’
compensation or similar laws.
Process and Proceedings: We may disclose your
protected health information in response to a court or
administrative order, subpoena, discovery request or
other lawful process, under certain circumstances.
Under limited circumstances, such as a court order,
warrant or grand jury subpoena, we may disclose your
protected health information to law enforcement
officials.
Law Enforcement: We may disclose limited
information to a law enforcement official concerning
the protected health information of a suspect, fugitive,
material witness, crime victim or missing person. We
may disclose the protected health information of an
inmate or other person in lawful custody to a law
enforcement official or correctional institution under
certain circumstances. We may disclose protected
health information where necessary to assist law
enforcement officials to capture an individual who has
admitted to participation in a crime or has escaped
from lawful custody.
Patient Rights
Access: You have the right to look at or get
copies of your protected health information, with
limited exceptions. You must make a request in writing
to the contact person listed herein to obtain access to
your protected health information. You may also
request access by sending us a letter to the address at
the end of this notice. If you request copies, we will
charge you 25¢ for each page, $15.00 per hour for staff
time to locate and copy your protected health
information, and postage if you want the copies mailed
to you. If the Practice keeps your health information in
electronic form, you may request that we send it to you
or another party in electronic form. If you prefer, we
will prepare a summary or an explanation of your
protected health information for a fee. Contact us using
the information listed at the end of this notice for a full
explanation of our fee structure.
Accounting of Disclosures: You have the right to
receive a list of instances in which we or our business
associates disclosed your non-electronic protected
health information for purposes other than treatment,
payment, health care operations and certain other
activities during the past six (6) years. For disclosures
of electronic health information, our duty to provide an
accounting only covers disclosures after January 1,
2011 [January 1, 2014] and only applies to disclosures
for the three (3) years preceding your request. We will
provide you with the date on which we made the
disclosure, the name of the person or entity to whom
we disclosed your protected health information, a
description of the protected health information we
disclosed, the reason for the disclosure, and certain
other information. If you request this list more than
once in a 12-month period, we may charge you a
reasonable, cost-based fee for responding to these
additional requests. Contact us using the information
listed at the end of this notice for a full explanation of
our fee structure.
Restriction Requests: You have the right to
request that we place additional restrictions on our use
or disclosure of your protected health information.
Except as noted herein, we are not required to agree to
these additional restrictions, but if we do, we will abide
by our agreement (except in an emergency). We are
required to accept and follow requests for restrictions
of health information to insurance companies if you
have paid out-of-pocket and in full for the item or
service we provide to you. Any agreement we may
make to a request for additional restrictions must be in
writing signed by a person authorized to make such an
agreement on our behalf. We will not be bound unless
our agreement is so memorialized in writing.
Confidential Communication: You have the
right to request that we communicate with you in
confidence about your protected health information by
alternative means or to an alternative location. You
must make your request in writing. We must
accommodate your request if it is reasonable, specifies
the alternative means or location, and continues to
permit us to bill and collect payment from you.
Amendment: You have the right to request that
we amend your protected health information. Your
request must be in writing, and it must explain why the
information should be amended. We may deny your
request if we did not create the information you want
amended or for certain other reasons. If we deny your
request, we will provide you a written explanation.
You may respond with a statement of disagreement to
be appended to the information you wanted amended.
If we accept your request to amend the information, we
will make reasonable efforts to inform others,
including people or entities you name, of the
amendment and to include the changes in any future
disclosures of that information.
Electronic Notice: If you receive this notice on
our website or by electronic mail (e-mail), you are
entitled to receive this notice in written form. Please
contact us using the information listed at the end of this
notice to obtain this notice in written form.
Notice of Unauthorized Disclosures: If the
Practice causes or allows your health information to be
disclosed to an unauthorized person, the Practice will
notify you of this and help you mitigate the effects.
Questions and Complaints
If you want more information about our privacy
practices or have questions or concerns, please contact
us using the information below.
If you believe that we may have violated your
privacy rights, or you disagree with a decision we
made about access to your protected health information
or in response to a request you made, you may
complain to us using the contact information below.
You also may submit a written complaint to the U.S.
Department of Health and Human Services. We will
provide you with the address to file your complaint
with the U.S. Department of Health and Human
Services upon request.
We support your right to protect the privacy of
your protected health information. We will not retaliate
in any way if you choose to file a complaint with us or
with the U.S. Department of Health and Human
Services.
Name of Contact Person: Stacy K.
Telephone: (619) 583-8160
Address: 6699 Alvarado Rd., #2201 San Deigo, CA 92120
